Will the PTSD diagnosis disappear?

Psychiatrist Gerald Rosen argues that the diagnosis of post-traumatic stress disorder (PTSD) should be abandoned because it just re-describes emotional reactions that would otherwise be diagnosed as depression or anxiety, and is increasingly used where there was never any clear trauma in the first place.

He’s made his case in an editorial for the British Journal of Psychiatry and debates his ideas in an engaging discussion in a BJP podcast.

PTSD is the only psychiatric diagnosis where a clear cause forms part of the diagnosis. The person must have experienced a life-threatening event to themself or others, and must have experienced intense fear, helplessness, or horror at the time.

If this is followed by intrusive memories of the event, increased arousal (feeling ‘on edge’), avoidance of any reminders and these are long-lasting and they interfere with everyday life, the disorder can be diagnosed.

The trouble is, all of these can be found in people who have not experienced classical ‘trauma’. Some people, including Rosen, are arguing that many of the normal reactions to negative events are now being described in terms of mental illness and the concept of PTSD is becoming meaningless:

Peer-reviewed articles have even discussed the possibility of developing PTSD from watching traumatic events on television. It has been suggested that rude comments heard in the workplace can lead to PTSD because a victim might worry about future boundary transgressions: the conceptual equivalent of pre-traumatic stress disorder. New diagnostic categories modeled on PTSD have been proposed, including prolonged duress stress disorder, post-traumatic grief disorder, post-traumatic relationship syndrome, post-traumatic dental care anxiety, and post-traumatic abortion syndrome. Most recently, a new disorder appeared in the professional literature to diagnose individuals impaired by insulting or humiliating events ‚Äì post-traumatic embitterment disorder. Even expected and understandable reactions after extreme events, such as anxiety and anger, are now referred to as ‘symptoms’.

This does not mean that anyone who becomes disturbed after a negative experience shouldn’t be helped, just that PTSD is not a useful way of guiding the treatment. Critics argue that the existing categories of depression and anxiety are more than adequate.

In the podcast, Rosen discusses the possibility that PTSD may be ‘popular’ as a diagnosis because it’s perfectly suited to the legal system.

It defines a cause and an effect, a compensation lawyer’s dream. This is more important for the American health care system where mental health treatment is often only reimbursed by the insurance companies if a doctor can make a diagnosis.

PTSD might be the only way for a doctor to get insurance companies to pay for treating someone who is having difficulty adjusting to a bad experience.

Interestingly, the diagnosis of PTSD was largely accepted into the diagnostic manuals due to pressure from campaigners wanting the US government to treat Vietnam veterans’ mental health needs on their return from the conflict.

A recent study checked the service records of Vietnam veterans who were being treated for PTSD and found only 41% had been exposed to combat, despite their being no difference in the symptoms between ‘combat’ and ‘no combat’ troops.

This isn’t to suggest that some veterans were ‘faking’, just that there isn’t always a clear connection between a traumatic event and the symptoms of PTSD.

With these points in mind, Rosen makes for an interesting guest on a diagnosis that we now tend to take for granted.

Link to BJP podcast ‘Problems with the PTSD diagnosis’.Link to PubMed entry for editorial.